Protected Disclosure Form

February 2022

Protected Disclosure Form

Please read the Protected Disclosure (Whistleblower) Policy and the Procedure for Filing a Protected

Disclosure prior to completing this form. This form should be use to report allegations of wrongdoing to

the University.

Please submit the completed form to the Designated Officer at

designatedofficer@mtroyal.ca

. You may

attach any additional relevant supporting documents.

YOUR INFORMATION

Date of this protected disclosure

report (YYYY/MM/DD):

First and Last Name:

Email Address:

Daytime Phone:

Are you an employee of Mount

Royal University?



Yes. Position:



No. Relationship to the University:

The personal information that you provide to Mount Royal University is collected under the authority
of the Post-Secondary Learning Act and the Freedom of Information and Protection of Privacy (FOIP)
Act – section 33(c). The information collected may be used in an investigation and may be shared
with the individual who the report is made against if necessary to investigate the incident in
accordance with the

Procedure for Investigating a Protected Disclosure.

Collected personal information is protected from unauthorized access, collection, use, and disclosure
in accordance with the FOIP Act and can be reviewed upon request subject to the provisions under
the Act. Questions regarding the collection of personal information can be directed to: Department
of Human Resources – Mount Royal University – 84825 Mount Royal Gate SW – Calgary – AB- T3E
6K6 – 403.440.6584 or

humanresources@mtroyal.ca

Protected Disclosure Form

February 2022

INFORMATION OF THE INDIVIDUAL(S) ALLEGED TO HAVE BREACHED THE POLICY

First and Last Name:

Individual’s Position Title:

Individuals Department:

Sub-Department:

Individuals relationship to you at

the University, if any:

(i.e., co-worker, manager, external contractor, professor, etc.)

First and Last Name:

Individual’s Position Title:

Individuals Department:

Sub-Department:

Individuals relationship to you at

the University, if any:

(i.e., co-worker, manager, external contractor, professor, etc.)

ADDITIONAL INFORMATION

Is this an urgent matter (Yes/No):

If yes, please describe briefly.

Urgent matters are those that have an

immediate need for an investigation (for

example, an imminent risk of specific or

substantial danger to life, health or safety

or a person or to the environment, or a

wrongdoing that is expected to occur in

the near future).



No.



Yes. Explanation:

Have you previous reported this

wrongdoing (either under this

policy or another one) (Yes/No):

If yes, please identify the date(s)

and person(s)/department(s) you

contracted and result of that

action. Please include a copy of

the report and response (in any).



No.



Yes. Explanation:

Are you concerned of any

potential reprisals to yourself or

others (Yes/No):

If yes, please describe briefly.



No.



Yes. Explanation:

Protected Disclosure Form

February 2022

ALLEGATIONS OF WRONGDOING

Type:

Please check the appropriate type(s) of

wrongdoing(s) which apply to the

allegation you are reporting.



A contravention of an act or a regulation of Alberta or

Canada.


An act or omission that creates:

•

A substantial and specific danger to the life, health or

safety of individuals other than a danger that is inherent

in the performance of the duties or functions of an

employee; or

•

A substantial and specific danger to the environment.



Gross mismanagement of public funds or a public asset.



Fraud.



Irregularity.



Knowingly directing or counseling an individual to commit a

wrongdoing mentioned above.

Description:

Please describe what the alleged

wrongdoing(s) is (are) about. Detailed

information is required to enable a full

review of the matter. Attach all

supporting documentation (if available).

Status of the wrongdoing:

Please check the appropriate status of the

wrongdoing. This pertains to whether the

wrongdoing as already occurred, is

ongoing, or will occur in the future.



Wrongdoing has already occurred.



Wrongdoing is ongoing.



Wrongdoing is expected to occur.

ADDITIONAL INFORMATION

Please provide any additional

information which may be useful

for reviewing the allegation:

List of Evidence and Relevant

Documentation.

Please provide any evidence or documentation which may be useful for

reviewing the allegation as an attachment to your submission.

DECLARATION
I believe that all the information provided is true to the best of my knowledge.*

________________________________

____________________

Signature of reporting person

Date

*Knowingly making a false or misleading statement is an offence pursuant to the Act.

Protected Disclosure Form

February 2022

WHAT HAPPENS NEXT
After submitted your completed form and any additional evidence or documentation, the following

steps will occur:

Within five (5) business days, the Designated Officer will send you an email acknowledging the

receipt of the Protected Disclosure Form.

The Designated Officer will review the contents of the Protected Disclosure Form with the

Discloser to determine if the Protected Disclosure was made in good faith and contains enough

information for the Designated Officer to assess the allegation under the

Procedure for

Investigating a Protected Disclosure.

PLEASE NOTE

•

If there is insufficient information provided, the investigation may not proceed or may be

discontinued;

•

By sending this report, you implicitly agree that the Designated Officer may contact you for

further information;

•

You will only be contracted by the Designated Officer for further information regarding the

submission of the Protected Disclosure Form, or by an investigated assigned by the Designated

Officer to investigate the report;

•

Information within the report may be shared by the Designated Officer for the purpose of

investigating the allegation. The identity of an employee making a protected disclosure may be

revealed subject to section 4 of the

Protected Disclosure (Whistleblower) Policy;

•

Allegations of wrongdoing can be made anonymously through the Confidence Line however, this

limits the ability of the University to respond an investigate. An employee who wishes to remain

anonymous may also make an allegation of wrongdoing directly to the Commissioner.